Monthly Archives: May 2013

Short sleep duration is common in adolescents and young adults, and is a risk factor for motor vehicle crash.

In the new study “Sleep-Deprived Young Drivers and the Risk for Crash – The Drive Prospective Cohort Study” published in JAMA Pediatrics, this first of its kind study found sleeping less on weekends puts young drivers at greater risk of having a car crash at night.

The authors of the study analyzed the association between sleep and motor vehicle crashes in newly licensed people aged between 17 and 24. Measuring a sample size of 20,000, the participants were followed up on average two years after being enrolled in the study.

Beginning in 2003, the researchers analyzed police-reported crash data and driver sub-groups to determine who had an increased crash risk. The study found that less sleep per night significantly increased young drivers’ crash risk and that less sleep on weekends increases run-off road and late night crash risks.

Other Studies
Leon Lack, Professor of Psychology at Flinders University and a sleep expert, said that other studies have shown that younger people tend to be higher risk takers in general.

“Even though, intellectually, they may appreciate they will be sleepy and should not be driving, in reality they may do so anyway,” said Professor Lack.

“We have recently done a nationwide study on sleepiness. As a group, people of this age tend to report more sleepiness. Sleepiness continues to be reported up to about the age of 50 and then tends to decline with older age groups,” he said.

“Sleep need of that younger age group is still quite high, an average of about eight hours a night with individual variations. Younger people are perhaps pushing the boundaries a little more than older people.”

Professor Lack said young people may feel they don’t have enough time for sleep.

“They may have a second job, they may be studying full time, they may be married and if they have young kids, they have a lot of commitments,” he said.

“That, in conjunction with potentially a bit of alcohol and the effect of circadian rhythms on late night driving, can have a very strong effect to produce extreme sleepiness.”

Sleep laboratories and sleep physicians have long complained that it’s difficult to make money with home sleep testing (HST). The key to making it work could well be to expand revenue-producing services associated with HST.

Hani Kayyali, president of Cleveland Medical Devices (CleveMed), believes the idea can work if sleep specialists can successfully reach out and offer interpreting and/or scoring services to ordering clinicians. Those healthcare providers could be primary care physicians (PCPs), nurse practitioners (NP), dentists, cardiologists, and many more providers who typically care for those patients all the time, are interested in adding sleep evaluation to their practice but desperately need sleep specialist’s oversight and disease management expertise.

“Some sleep labs are facing considerable challenges due to losing their referrals to mail-order Home Sleep Testing, worsening no-show rates, or high cost structure and PSG-based workflow that cannot be re-factored easily to handle the lower reimbursement HST,” explains Kayyali from his Ohio-based office, “but our web portal technology allows those local sleep labs and / or sleep physicians to expand the reach of their sleep services and to make up for some of the lost revenues by scoring and interpreting sleep studies — even though patient screening and home sleep testing are initiated from a different site.”

“Once screened for OSA by the healthcare provider, patients go home with the SleepView monitor and self-administer it that same night”, says Kayyali, “next day, practice staff can upload the data to our web portal, which is then forwarded to RPSGT and sleep physician for scoring and interpretation. Guided by the sleep doctor’s diagnostic report, which includes therapy recommendations, the ordering provider would then initiate treatment or send the patient to the sleep lab for more extensive workup if needed. The whole point is that sleep labs now have a tool that can easily deliver their professional services to other practitioners. In addition to study reads, sleep specialists can offer other valuable clinical expertise such as training providers on screening, care pathways, and others”.

While CleveMed has its own network of sleep physicians licensed in all 50 states, Kayyali maintains that the recently-added web portal flexibility allows any practice to seamlessly assign sleep studies to qualified sleep scorers or physicians of their choosing, which can strengthen local relationships and enhance the continuity of patient care. “Our overall web portal adoption is seeing double digit growth every month” adds Sarah Weimer, director of Sleep Products at CleveMed. “Many healthcare providers want to adopt HST. They see sleep apnea patients all the time and hear of their symptoms before anyone else. These providers frequently request local sleep specialists to provide oversight, which can be easily done with our newest web portal release.”

According to Kayyali, making it convenient for healthcare providers to initiate care for sleep disordered breathing will not only generate revenue for both the ordering physicians and sleep specialists, but more importantly has immediate patient care benefits as it can speed diagnosis and treatment. For example, research done by CleveMed showed that the entire process from the time the patient first discusses symptoms with their primary care provider to diagnosis was 3.1 days.

Within the Realm of Primary Care Settings?

The healthcare system has always recognized the need to improve delivery of care of chronic diseases like hypertension, diabetes, and asthma, and many believe that the recent focus on care coordination between primary care and specialists will help achieve that goal. “Sleep apnea is now being bundled with those high cost chronic diseases and I believe that the various healthcare stakeholders can peacefully coexist with the CleveMed model”, Kayyali says. “As long as sleep physicians maintain oversight on scoring, interpretation and follow-up, sleep labs could accept a Provider Practice-based HST Model.”, he says.

Kayyali says clinical guidelines for portable monitoring do not preclude non-sleep specialists from screening and initiating the sleep test. “Practice staff like nurse practitioners and physician assistants has been trusted for decades to care for complex diseases like asthma and diabetes. So, there is no reason to doubt their ability to handle OSA including administering sleepiness questionnaires, training on monitor sensor hookup, and others as evidenced by research findings,” says Kayyali. “Furthermore, due to the strong on-going patient-doctor relationship and the face-to-face training in the office, it is expected that compliance with HST and eventually treatment will likely be higher than any other HST model. However, as said before, identifying at-risk patients and dispensing monitors is only one piece of the puzzle and must always be complemented with sleep specialty oversight whether it is for baseline diagnosis or follow-up management to ensure proper continuity of care. That is why the clinical guidelines correctly require that studies be scored by registered sleep technologists and read by board certified sleep physicians “, he says.

While not all insurance carriers reimburse for Provider Practice-based HST, healthcare in general and third party payers in specific are demanding improved delivery of care while avoiding traditional in-lab costs, “Our technologies allow various stakeholders to be engaged, who together offer a more efficient solution to the patient without compromising care or burdening any one entity with all the work”, says Kayyali.

Ultimately, Kayyali says, “Our long-term success in controlling the spiraling human and financial costs of chronic diseases, including sleep apnea, must incorporate a pivotal role for primary care practitioners including the new and emerging workforce; nurse practitioners and physician assistants. The sooner we incorporate their skills in sleep apnea care pathways the better off we will all be”.

As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy.

Several news outlets, seized on the new study, essentially saying that the widely-performed surgical procedure “can reduce sleepiness and improve the quality of life, but putting off the surgery might not hurt either.”

In an article by Reuters reporter Gene Emery, Dr. Susan Redline of Boston-based Brigham and Women’s Hospital conceded that “Where you objectively measure these cognitive tasks, children can do fairly well in that motivated and structured environment” whether or not they have surgery.

Children with the surgery showed a large improvement on ratings of things such as impulsiveness, emotional control, and quality of sleep that were assessed by parents and teachers. “It really was across-the-board improvement in everyday life for surgery patients,” Redline said in the Reuters article. On the other hand, Redline added that “almost half the children improved spontaneously over the 7-month period without surgery.”

Evidence for the obesity/sleep apnea connection is mounting, but asthma is back on the radar thanks to researchers at the University of Wisconsin (UW).

In a new study “Asthma Predicts 8 Year Incidence Of Obstructive Sleep Apnea In The Wisconsin Sleep Cohort“ presented at the recent American Thoracic Society meeting in Philadelphia, PA, researchers used data from a National Institutes of Health (Heart, Lung, and Blood Institute) and Wisconsin Sleep Cohort Study, which followed approximately 1,500 people since 1988. Patients who had asthma were 1.70 times (95% CI=1.15-2.51) more likely to develop sleep apnea after eight years.

“This is the first longitudinal study to suggest a causal relationship between asthma and sleep apnea diagnosed in laboratory-based sleep studies,” said Mihaela Teodorescu, MD, MS, assistant professor of medicine at UW, who will present the research at ATS 2013. “Cross-sectional studies have shown that OSA is more common among those with asthma, but those studies weren’t designed to address the direction of the relationship.”

Pediatric asthma patients had an even stronger likelihood to develop sleep apnea later in life. Specifically, childhood-onset asthma was associated with 2.34 times (95% CI=1.25-4.37) the likelihood of developing sleep apnea.

Researchers also found that the duration of asthma affected the chances of developing sleep apnea. For every five-year increase in asthma duration, the chances of developing OSA after eight years increased by 10 percent.

It’s not difficult for sleep physicians to predict which patients are most likely to have sleep apnea. The latest study from researchers at the University of Wisconsin-Madison (UWM) confirms the patient profile, adding more evidence to the widely held belief that obesity is, at least in part, fueling a rise in sleep apnea.

Originally published in the American Journal of Epidemiology “Increased Prevalence of Sleep-Disordered Breathing in Adults”.

“There are probably 4 million to 5 million people who are more likely to have sleep apnea due to the obesity epidemic,” says Paul Peppard, PhD, assistant professor of population health sciences at UWM in an article by Traci Pedersen. “It’s certainly an uncalculated cost of the obesity epidemic, an epidemic of its own.”

Specific findings show a sizable spike in sleep apnea cases over the past two decades—as much as 55%. The study involved more than 600 adults, ages 30 to 70, who underwent sleep tests between 1988 and 1994—with some continuing to take part along with hundreds of new participants from 2007 to 2010.

Pedersen summarizes that among all groups, heavier people were much more likely than thinner people to suffer from sleep apnea. Peppard estimates that 80% to 90% of the increase in symptoms is due to the growth in obesity.

Sleep Scholar for Sleep Medicine Professionals

Editors Choice

Adverse outcomes have been reported in the perioperative setting in patients with known or unrecognized obstructive sleep apnea syndrome (OSAS). Although epidemiologic data report a prevalence of OSAS at about 5%,1 patients presenting to surgery have an estimated prevalence of 1–9%, or even higher in certain surgical categories.2 Ashton et al. studied 1487 men older […]